Random thoughts on almost anything and everything, with an emphasis on defense, intelligence, politics and national security matters..providing insight for the non-cleared world since 2005.

Thursday, July 23, 2009

The Shape of Things to Come?

Whenever the subject of health care reform comes up, there is almost no mention of the "single payer" system that's already at work in the United States.

And no, we're not talking about the gold-plated program for our elected officials, or the premium plans available to most federal and state employees. Many Americans forget about another group of government workers who make do with limited choices and care that is sometimes awful.

The "employees" in this case are members of the U.S. armed forces. Their health care is largely provided by the military's network of doctors, hospitals and clinics. The system is based on the obvious need to create a system capable of caring for personnel injured in combat. It is also a long-standing "benefit" of military service, promising low-cost (or "no cost") care for service members and their dependents.

To be fair, many military doctors and treatment facilities have a well-deserved reputation for excellence. The Air Force mobile hospital at Balad AB near Baghdad has saved literally thousands of wounded troops; many go on to state-of-the-art rehabilitation centers in the U.S. that have produced their own share of miracles.

But talk to anyone who's served in the military for any length of time, and you'll hear horror stories about a system that is often inadequate. In some cases, base pharmacies don't stock the latest medicines due to cost. Advanced medical treatment is also difficult to obtain; the only transplants conducted at military hospitals are kidney transplants, a procedure that was only offered decades after their introduction at civilian facilities.

In other cases, military medicine can kill you, or leave a patient disabled for life.

Laparoscope surgeries to take out a gallbladder have become routine in recent years. Doctors across the U.S. perform the procedure hundreds of times every day. But something went terribly wrong during Airman Read's surgery. Somehow, the surgical team nicked or punctured his aorta, the large blood vessel that carries blood from the heart to other parts of the body. Doctors managed to repair the damage enough to save Read's life, but the tear began leaking, disrupting blood flow to the lower extremities.

Airman Read was airlifted to the UC Davis Medical Center, where surgeons were forced to amputate both legs. Over the past two weeks, he's undergone 10 additional surgeries to remove dead tissue from what's left of his lower limbs. Meanwhile, the diseased gallbladder is still in his body; complications from the original, botched surgery have prevented surgeons from removing it.

The Air Force has launched an investigation into what went wrong in the operating room. Airman Read's military career is likely over and his family cannot sue the doctors who almost killed him. Thanks to a federal law called the Feres Doctrine, members of the armed forces (and their families) can't sue military doctors who make catastrophic medical mistakes.

A bill now before Congress would end the prohibition. Normally, we're not friends of the tort bar, but this is one situation which cries out for legal remedy.

What happened to Colton Read is hardly isolated. An organization called Veterans Equal Rights Protection Advocacy (VERPA) claims that hundreds of military members have died or left permanently disabled by incompetent military doctors. From our own experience, we know of cases where members of the armed forces were misdiagnosed.

In one example, a retired NCO was told his severe chest pain was nothing but "indigestion," and sent home. He died hours later of a massive heart attack. At the same military hospital, a woman complaining of low back pain was given Motrin and told to "rest." Two weeks later, she was diagnosed with terminal liver cancer. The Air Force doctor who made the original, mistaken diagnosis was later reassigned to administrative duties, not as a result of the mistake, but because the service couldn't confirm that the man (who was born overseas) had actually graduated from medical school.

If you want a taste of nationalized health care, just take a look at the military medical system. Some of us have seen the future--or Barack Obama's version of our medical future--and it isn't pretty.

I am married to an active duty Army colonel who is in medical administration. As long as he has been in the service his only goal has been to make sure that the nation's finest have access to the best medical care around. I could never count the hours he has spent and the family time he has sacrificed in search of this goal. And he is not the only one doing this. He works with and has worked with thousands of professionals dedicated to the same thing. The incident you describe is a tragedy but you know what? The civilian medical system can kill you too. It is fraught with difficulties and problems too. I'm a nurse in a civilian hospital and see the issues everyday there. Civilians have plenty of horror stories too. The real problem with nationalized health care for civilians is it will never work as well as the military system - for many reasons. I don't think you have made a good comparison here.

Mary makes some good points and I agree with her assessment that the proposed national health care plan(s) will not work as well as what we have in the military today. The reasons are legion but that is not what I want to bring up here.

As someone that has been a benefactor, participant, waiting room occupant, etc., of/in the military health care system as both a dependent and service member for nearly 50 years, I have personally observed both extremes of performance, good and bad.

The DoD system is large and cumbersome, so not surprisingly change such as modernization sometimes comes slowly. The DoD is possibly the best example I can point to from personal experience that allows me to confidently say that if we get a big, all singing, all dancing solution to civilian medical health care, nobody should labor under the illusion that it will be responsive to changing needs, technologies, etc., in the way you would expect based on your current experience in the civilian world. Bureaucracy, budgetary, political reasons and a host of other factors will now be a daily influence on your health care in ways you've never encountered before.

I've consistently found that the best military health care is to be had at the smaller clinics. Mary is probably familiar with Tripler AMC and certainly with Walter Reed but as someone that has been assigned within the regions they served, I picked out small Navy and Air Force clinics for my own care and that of my dependents. When you need a referral for a service or specialty not available at that location, you go somewhere else, quite often to a civilian provider. Which brings me to an important point and that is to say that our current military health care system would all but collapse if not for the existence of TRICARE and the civilian facilities and personnel that it makes available to support our needs when the military alone cannot.

I've been lucky in that I've been able to choose who would provide our care. What will happen if the government gets to dictate that choice to civilians? It may not be the case for all or even most patients at the onset but it will certainly happen to some and it will most likely become the rule. Consider, for example, that the UK's National Health Care system designates your provider by Post Code.

Closer to home, my home anyway, what would happen to active duty and dependent referrals and the medical treatment of retired personnel if our civilian system becomes inundated under the crush of national health care "reform"?

For decades active duty personnel have accepted lower pay for the promise of the delayed financial advantages of what has become known these days as "TRICARE for Life". I'd like to hear Congress explain how they will square that deal. I know it won't happen but I feel that as I retire this year that maybe I'm "entitled" to better retirement pay considering that I sucked it up at low pay for better than half of my career (when I consider what my civilian counterparts were earning) because of the perceived value of medical benefits available to my wife and I when I retired.

The shortsighted habits of our legislature is nowhere more evident than in this current example of "make it up as we go along" planning.

Do you wonder if they have they stopped to consider what they will lose in retention incentives for traditional career military personnel when they've effectively undercut military medical care? I seriously doubt that it has entertained a second thought in the minds of many, if any, members of Congress or the President himself.

The Congress, which is responsible for raising and maintaining our Armed Forces for the President to lead in the defense of our nation, is going to be faced with an increasingly difficult task of keeping mid-career personnel on the rolls. These future senior leaders of our military are not likely to be enticed to stay for increased salaries alone and furthermore, will there be sufficient funding for even that enticement? The debate has opened up many questions to consider but there are still so many more unintended consequences possible in this ill-conceived endeavor.

As far as I'm concerned the election is over and the Congress and the President should be more concerned about living up to their current duties as outlined in the Constitution as opposed to adding still more and larger responsibilities for the government.

Talking about health care "reform" as a function of campaign rhetoric is like dangling a piñata at a kids party. Loud, little people with hats get excited about the prospects even though they cannot see what is exactly there. Letting politicians actually "work" on health care "reform" is more akin to wearing the piñata as a hat.

not being familiar with the military medical system let me ask those of you that the following...

would it make sense to set up mash units, on a rotating basis, to service both inner city urban populations (that use emergency rooms for non emergency usage) and rural locations that lack reliable access?

these mash units could by their very nature we used to train nurses, doctors, lab tech & such thus providing a trained medical stuff that could go seamlessly into the private sector trained and ready to work in an area of the economy plagued by shortages...

increasing supply of doctors, nurses etc would increase supply and in theory drive down costs...

If the average MD today earns $437.000 and there is a major shortage of General Practice MDs why not increase supply, shorten wait times and provide more competition?

Let's be honest: What happens to a doctor who graduates *last* in his class, and doesn't want to go back to school so he can rubberstamp prescriptions as a psychiatrist and doesn't want to deal with bodies as a medical examiner? How do they pay off a huge student loan load, when no practice or hospital wants them, and no insurance company will cover them for malpractice?

They join the military, who will pay off their debt, put them into a hospital, and shield them from any and all lawsuits. Not all military doctors suck, but those that stay in longer than it takes to neutralize their student loan debt usually do.

Also, military protocol encourages a throwback attitude towards patients as bags of meat that do what they're told, rather than participating in their care decisions.

A much more fair comparison would be to the VA, which manages to do excellent work in general in spite of insane red tape, inadequate budgets, and (lately) excessive privatization. But that would be for something equivalent to Britain's National Health Service, not a single-payer plan such as they are currently pushing.

For an equivalent to that, you have to look to Medicare, Medicaid, and SCHIP, all of which service populations that would otherwise be uninsured, and do so far more cheaply per patient than private insurance. If it weren't for them, our health system would already have collapsed under the contradictions of "You get what you can pay for" and the mandate to treat patients who can't pay, rather than leaving them to die in a charity ward or on the street.

Correction: They are not pushing single-payer such as Canada's system, but a "Public Option" insurer of last resort. As a small businessman, I'm praying this goes through. Have you ever tried to negotiate a group health plan for a group of a couple of dozen?

The mere existence of a public option would keep private insurers honest, and that's what they're really fighting to keep: A system in which all the competitive pressures are in favor of reduced care and choice, and higher profits.

Correction: They are not pushing single-payer such as Canada's system, but a "Public Option" insurer of last resort. As a small businessman, I'm praying this goes through. Have you ever tried to negotiate a group health plan for a group of a couple of dozen?

The mere existence of a public option would keep private insurers honest, and that's what they're really fighting to keep: A system in which all the competitive pressures are in favor of reduced care and choice, and higher profits.

"...over the course of this decade, the state of Oregon has put in place a formal procedure for rationing care to patients whose health coverage is subsidized by government (i.e., who are enrolled in some form of the state’s “public option”)..."

"...under the state’s rationing procedure, a person in need of an emergency appendectomy (prioritized 84th by the the state of Oregon) would be denied that treatment before an individual in need of treatment for “tobacco dependence” (ranked 6th)..."

"...the bureaucrats who designed the priority structure in this “public option” program determined that the use of taxpayer funds for abortion is more important (and more medically necessary) than covering injuries to major blood vessels (ranked 86th), surgery to repair injured internal organs (88th), a “deep wound to the neck” or open fracture of the larynx or trachea (91st), or a ruptured aortic aneurysm (306th)..."

"...treatment for esophogal, liver, and pancreatic cancers take up priority slots 337 through 339, with treatment for stroke at 340 — all over 300 places behind Obesity (8!), Depression (9), and Asthma (11)..."